Provider Demographics
NPI:1730255548
Name:SO PASADENA OB & GYN MEDICAL GROUP
Entity type:Organization
Organization Name:SO PASADENA OB & GYN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-577-8058
Mailing Address - Street 1:10 CONGRESS ST STE 403
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3023
Mailing Address - Country:US
Mailing Address - Phone:626-577-8058
Mailing Address - Fax:626-440-9976
Practice Address - Street 1:10 CONGRESS ST STE 403
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3023
Practice Address - Country:US
Practice Address - Phone:626-577-8058
Practice Address - Fax:626-440-9976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40118146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0058170Medicaid